Resource Overkill: We Can Do More for Less

Thursday, March 5, 2009
A.J. Heightman, MPA, EMT-P

One of my favorite scenes from the classic movieA Christmas Storyis when Ralphie and his friends triple-dog-dare Flick to put his tongue on the fro__zen flag pole. Naturally, it adheres to the pole immediately, and before long you hear the whine of sirens. An engine company and ˙cop carÓ arrive to rescue Flick. Sending nine people to rescue him was clearly overkill. Flick_s teacher could have easily trickled a cup of warm water on his tongue to free him.

Do you over-commit resources in your EMS system? Do you send the band when a trumpet player would suffice? We often send six to eight responders to incidents where one would probably do. And, in many areas, we do it Code 3 via a combined EMS and fire response, risking apparatus that costs a half-million dollars and subjecting personnel to intersection collisions that could kill them.

Worse yet, we often do it for reasons that don_t make sense in this day of computerized dispatch, medical priority dispatch and a tenuous economy.

Some of the morale problems I witness come from what I call ˙resource overkillÓƒthrowing excessive and expensive resources at BLS (alpha-level) responses and burning out the responders forced to ˙mount upÓ and respondƒen masseƒto calls that don_t really need them.

I never hear first responders complain about assisting ambulance crews at true ALS calls, cas_es where patients require more than an IV. But just 20% of all EMS calls are ALS in nature, with probably 25Ï50% of that total representing critical patients who need an all-hands approach. I don_t think we should mess with the response to these calls. You can send an ALS ambulance, ALS engine and ALS drone aircraft to these cases if you want.

You also need the whole band at entrapments, complicated fractures, spinal immobilizations and special-needs calls. These include treating and moving morbidly obese patients, multi-floor transfers, assault victims and other cases that require extra manpower.

But sending the whole band for a child with a skinned knee is a waste of valuable resources. Large municipal systems need to more wisely deploy resources to these types of calls, which comprise the remaining 80% of call volume, especially in light of reduced budgets, fire station closures, traffic density and escalating call volumes.

It costs close to a half-million dollars to staff one ALS ambulance on a 24/7 basis (see Tables 1 and 2). Many systems deploy doz_ens of ALS ambulances and paramedic engines to manage the 20% of their call volume that requires ALS in a timely manner. But, day after day, these same systems are overburdened by walking wounded BLS calls and complain about ˙running out of ambulances.Ó

Instead of adding one ALS ambulance, a large EMS system could retrofit three decommissioned police vehicles, stock them with BLS gear and AEDs, and staff them with solo EMT-intermediates for the same budget expenditure. Or, they could buy two new cars and assign paramedics to them. These first responders could be sent to pure BLS calls, stop the response clock and manage a significant percentage of these calls, freeing up their full ALS resources for higher acuity calls (seeTable 1 andTable 2).

In cities with 200,000 people or fewer, it may make sense to continue committing four-person engines to assist ambulance crews on every call regardless of severity. But in busy fire first-response systems with proper call screening and medical priority dispatch protocols in place, it_s time to think outside the box and more efficiently deploy our EMS resources.JEMS